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General NPI Number Information
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NPI Number | 1952596579
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Entity Type | Organization
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Legal Business Name | COLCHESTER FAMILY MEDICINE LLC
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Dates
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Enumeration Date | 09/06/2007
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Last Update Date | 08/19/2008
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Provider Practice Location Address
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Address Line | 123 BROADWAY ST
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City | COLCHESTER
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State | CT
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Zip | 06415-1022
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Country | US
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Telephone | 860-537-3204
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Fax | 860-537-3208
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Provider Business Mailing Address
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Address Line | 123 BROADWAY ST P.O. BOX 288
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City | COLCHESTER
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State | CT
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Zip | 06415-1022
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Country | US
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Telephone | 860-537-3204
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Fax | 860-537-3208
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | OLAWALE AYENI
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Credential | MD
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Telephone | 860-537-3204
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 041093
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License Number State |
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